CPT 99497E&M

Advncd care plan 30 min

CPT 99497 covers the first 30 minutes a healthcare provider spends discussing advance care planning with a patient, including conversations about future medical decisions, living wills, and healthcare proxies.

Showing rates for

National Average

Base Medicare rate

$79.57

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

1.5

PE RVU (NF)

0.86

MP RVU

0.1

Total RVU

2.46

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Document exact start and stop times for the advance care planning discussion, ensuring at least 16 minutes of face-to-face time to meet the threshold for 99497
Impact: Failure to document times or billing with less than 16 minutes risks $79.57 denial; use 99498 for additional 30-minute increments beyond the first 30 minutes
Always append modifier 33 to Medicare claims for 99497 to waive patient cost-sharing as required under preventive service rules
Impact: Prevents patient billing for copay/deductible and avoids compliance issues; modifier is mandatory for Medicare, not optional
99497 can be billed on the same date as an annual wellness visit (G0438/G0439) or other E/M service when using modifier 25 and documenting separate, identifiable services
Impact: Increases revenue by approximately $79.57 per visit when advance care planning extends beyond the wellness visit scope; requires distinct documentation
Bill separately from the base E/M service even during initial consultations for seriously ill patients; this is not included in standard E/M time calculations
Impact: Recovers previously unbilled counseling time worth $79.57 per 30-minute session that many providers were absorbing into standard visits
Document specific advance directive forms reviewed, completed, or discussed, including patient goals, values, and preferences for life-sustaining treatment
Impact: Detailed documentation supports medical necessity and reduces audit risk; vague notes like 'discussed advance directives' frequently trigger recoupment of the $79.57 payment
When billing with 99498 (each additional 30 minutes), ensure total time exceeds 46 minutes (16 min for 99497 + 31 min for first unit of 99498) and document continuous session

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Frequently asked questions

How much does Medicare pay for CPT code 99497 in 2025?

Medicare pays $79.57 for CPT 99497 in 2025 under the non-facility rate (national average) and $72.46 under the facility rate. The code has 2.46 total RVUs (1.5 work RVU, 0.86 non-facility PE RVU, 0.1 MP RVU) multiplied by the 2025 conversion factor of 32.3465.

What is the minimum time required to bill CPT 99497?

CPT 99497 requires a minimum of 16 minutes of face-to-face time for advance care planning discussion. This is based on the midpoint rule for a 30-minute code, where you can bill when you reach the midpoint between the initial code and the next increment. You must document exact start and stop times to support the time spent.

Can CPT 99497 be billed with an annual wellness visit?

Yes, CPT 99497 can be billed on the same day as an annual wellness visit (G0438 or G0439) when modifier 25 is appended and the advance care planning discussion is separately identifiable and documented beyond the advance care planning element already included in the wellness visit. Both services must be medically reasonable and necessary with distinct documentation.

Do Medicare patients have to pay a copay for advance care planning CPT 99497?

No, Medicare patients have no copay, coinsurance, or deductible for CPT 99497 when billed with modifier 33. The Affordable Care Act designated advance care planning as a preventive service exempt from cost-sharing. Billing without modifier 33 will incorrectly trigger patient cost-sharing and violates Medicare requirements.

What is the difference between CPT 99497 and 99498?

CPT 99497 covers the first 30 minutes of advance care planning, while 99498 is an add-on code for each additional 30 minutes beyond the first. You cannot bill 99498 without first billing 99497. To bill both codes, you need at least 46 minutes total (16 minutes minimum for 99497, plus 31 minutes for the first unit of 99498).

Can nurse practitioners and physician assistants bill CPT 99497?

Yes, qualified non-physician practitioners including nurse practitioners, physician assistants, and clinical nurse specialists can bill CPT 99497 independently for Medicare patients without physician supervision. They receive 100% of the physician fee schedule amount for advance care planning services.

Can CPT 99497 be billed via telehealth?

Yes, CPT 99497 can be billed for telehealth visits using real-time interactive audio and video telecommunications. Append modifier 95 (or GT, depending on payer) to indicate telehealth delivery. The service must meet the same documentation and time requirements as in-person visits, and the non-facility rate of $79.57 applies for telehealth services in 2025.